In his film Madness and Civilization, Teemu Mäki examines the relation between deadly violence and concepts of insanity and disorder. This is done through cases of Anders Behring Breivik from 2011 and Pierre Rivière from 1835. The latter was in the focus of Michel Foucault whose bohemian and eccentric character is present in the film.

The suspense of the film is created by the weird and horrendous nature of the two cases. According to his own depiction, Rivière premeditatedly killed his own mother, sister and brother with a motive of freeing his father from suffering. Breivik had clearly premeditated political motives to kill 77 people that he did not know.

As such, the film does not take stand on these tragedies but they are shown. Michel Foucault is portrayed as a hedonistic intellect, who criticises the historical role of forensic psychiatry as a force of societal power.

From the perspective of forensic psychiatry, these cases are linked by their exceptional nature and the fact that they are somewhat difficult to interpret. The determination of responsibility or irresponsibility that sends the accused to prison or hospital is almost always possible to justify clearly and indisputably by thorough examination of the person’s life course and medical condition. However, there are rare cases on the border of the categorisation. Paradoxically, since 1889 in Finnish law it has been possible to give shorter sentences based on diminished responsibility. The verdict does not include involuntary treatment and the dangerous violent criminal can be freed and without control sooner than usual. Therefore, the option is rarely used and most forensic psychiatrists are ready to abolish it.

The forensic psychiatric system in Norway is decisively weaker compared to Finland. Mental examinations are conducted in diverse circumstances and the training of the examiners or used methods haven’t been standardised and aren’t as closely monitored as in Finland. It is almost certain that Breivik’s first paranoid schizophrenia diagnosis could not have been made in Finland. Over four years of observation has confirmed that he does not suffer from psychotic disorder.

Mental patients who suffer from paranoid delusions commit violent crimes very rarely towards people other than their family or living partners. Typically such crimes are committed in psychotic terror, without premeditation and by whatever is at hand. The estimated number of homicides of strangers committed by psychotic persons is one in 14,3 million, which means one case in Finland or Norway every two to three years. On average, there are over 100 homicides in Finland per year and one in ten is committed by a psychotic person.

Rivière’s case resembles more a homicide committed by a psychotic person than Breivik’s systematic mass murder and the recorded history shows many psychotic features in Rivière’s story. Nowadays in Finland in three out of four homicides committed in psychosis, the person also has a substance abuse problem, personality disorder or both and therefore the crime cannot be fully explained by the psychosis.

Psychiatry is a practical specialist field of medicine. We know that the homicide risk linked to the first psychotic episode is reduced to one fifteenth through psychiatric care, for example, antipsychotic medication. So if a psychiatric rehabilitation centre moves next door, do not be worried. The changes are that you, in fact, are more dangerous.

However, the risk is higher when psychosis is treated with homeopathy, herbs or prayer. Family members have been killed in these kinds of cases of ineffective treatment and neglect during past years also in Finland.

The presumption in mental examination is full responsibility and irresponsibility has to be convincing and the evidence of it has to be understandably explained. Our system works well in taking the individuals who act violently under psychosis into progressive rehabilitating care lasting years and sometimes the rest of one’s life instead of convicting these individuals to imprisonment. Commonly, this kind of treatment is given in Niuvanniemi or Vanha Vaasa hospital. According to the two-step process, the patient can be released into non-institutional care, monitored by the National Institute for Health and Welfare, only when the disorder and its treatment are in good control and there is no risk of violence in sight. This prevents the repetition of the offence significantly more effectively than imprisonment from where the person is released on a set date without any evaluation of change in behaviour. The system prevents human suffering in many ways. The problems with borderline cases are approached pragmatically: the accused is sentenced to prison but if the disorder gets worse and is untreatable in prison conditions, the sentence is discontinued and progressive, involuntary treatment starts.

It is a good idea to view ethical questions from different perspectives but from the viewpoint of forensic psychiatry, Michel Foucault’s criticism against control society and institutionalised psychiatry is not a plausible theory with practical applications. His interpretations disregard almost entirely the fact that already in the 19th century hospitals and institutions provided help and safety for the weak, who lived a in world that was cold and cruel and ruthlessly controlled. The establishment of care systems have been motivated by the need for control and philanthropy.

There are many comprehensive presentations of the history of psychiatry written by professional historians where Foucalt is not present even in the footnotes. The reason is, as I understand, that the radical philosopher based his views more on flowing mental images than on systematic study of history. 

Hannu Lauerma

MD, specialist in psychiatry and forensic psychiatry, psychotherapist  

Chief Medical Officer, Psychiatric Hospital for Prisoners

Docent, University of Turku

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